ORIGINAL RESEARCH Open Access Air ambulance services in the Arctic 1999-2009: a Norwegian study Jan Norum 1,2,3* , Trond M Elsbak 3 Abstract Background: Air ambulance services in the Arctic have to deal with remote locations, long distances, rough weather conditions and seasonable darkness. Despite these challenges, the people living in the area expect a high quality of specialist health care. Aims: The objective of this study was to analyse the air ambulance operations performed in the Norwegian Arctic and study variations in diagnoses and flight patterns around the year. Methods: A retrospective analysis. All air ambulance operations performed during the time 1999 – 2009 period were analysed. The subjects were patients transported and flights performed. The primary outcome measures were patients’ diagnoses and task patterns around the year. Results: A total of 345 patients were transported and 321 flights performed. Coronary heart and vascular disease, bone fractures and infections were the most common diagnoses. Most patients (85%) had NACA score 3 or 4. Half of all fractures occurred in April and August. Most patients were males (66%), and one fourth was not Norwegian. The median flying time (one way) was 3 h 33 m. Ten percent of the flights were delayed, and only 14% were performed between midnight and 8.00 AM. The period April to Augu st was the busiest one (58% of operations). Conclusions: Norway has run a safe air ambulance service in the Arctic for the last 11 years. In the future more shipping and polar adventure operations may influence the need for air ambulances, especially during summer and autumn. Introduction The Northern Norway Regional Health Authority (NNRHA) trust is responsible for the specialist health care service and all patient transportations in northern Norway. This includes the Norwegian Arctic areas (Svalbard, Bear Island, Hopen and Jan Mayen). Sval bard is a group of islands reaching up to the 80th degree northern latitude and covers an area of 61,020 km 2 . The land area constitutes 16% of Norway. The largest island is Spitsbergen, and its municipalities are Lonyearbyen, Barentsburg, Svea, Hornsund and Ny-Ålesund. The main airport is located at Longyearbyen, but there is also a minor one at Svea. The main i ndustries on the island are coal mines, tourism, education, research and satellite services. According to data from Statistics Norway (www.ssb.no), as of January 2009 there were a total of 2,570 inhabitants (2,085 Norwegians, 470 Russians and 10 Poles) on the island. There is a rich fishing area in the Svalbard zone, and fishermen from various nations such as Great Britain, Germany, Spain, Portugal, R ussia, Iceland, the Faroe Islands and Norway fish in the area. Whereas people living in the Arctic experience sea- sonable darkness and polar nights, the summer is light. For example, Longyearbyen experiences 4 months of seasonable darkness (no sun; 7 October – 8March), including 2 months (14 November – 30 January) with complete darkness (“polar night”). “In compensation”, there are 4 months of midnight sun d uring the summer (20 April – 23 August). The Norwegian health care service in the region is provided by a small hospital unit in Longyearbyen. The unit is run by the University Hospital of North Norway (UNN) trust and is staffed with three medical doctors (one surgeon and two general practitioners). According to standard procedur e, at least one doctor stays on the * Correspondence: jan.norum@helse-nord.no 1 Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway. Full list of author information is available at the end of the article Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 © 2011 Norum and Elsbak. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the ori ginal work is properly cite d. island at all t imes. Due to the limited staff, the hospital serves as a “preparedness hospital” taking care of pri- mary health care, casualties and emergency care. Rou gh weather condit ions, often presenting with strong winds, ice, cold temperatures and seasonable darkness, intr o- duce challenges to health care in the Arctic. Long dis- tances and almost no alternatives for landing make it necessary to be very cautious concerning safety before and during flights. Peoples’ activities in the Arctic vary significantly around the year. The coal mines have reduced activity during the summer, fisheries experience limited access to t he northern regions in winter because of enlarged polar ice coverage, cruise liners mainly oper- ate in the area during summer, and polar adventure activities employing dog sleds or snowmobiles mainly take place during periods with daylight and snow (mainly spring and autumn). Based on this knowledge, we aimed t o clarify the variations in patients’ diagno ses and flights pattern around the year Methods The Arctic is shown in Figure 1. Despite the remote location, the population at Svalbard requests health care of similar quality to that offered on the mainland. An efficient air ambulance service is of utmost importance to meet these expectations. To administrate the service, the four Regional Health Authority (RHA) trusts have together established a company named Luftambulanse tjenesten ANS (www.luftambulanse.no). The company registers all air ambulance activities in the LABAS data- base, employing a specific report sheet filled out by the medical crew (specialised nurse or medical doctor). Furthermore, they administrate finances for the supply of air ambulance operations. In northern Norway, the operations have been performed by the company Lufttrnsport AS (www.lufttransport.no). They employ Beechcraft King Air 2002/B200 airplanes and Augusta AW 139 helicopters. Air operations by the Norwegian Coast Guard (NCG; employing Lynx helicopters onboard), the Governor of Svalbard (GoS; operating a Super Puma helicopter at Longyearbyen), the Norwegian Air Force (NAF; operating Sea King helicop- ters at Banak and Bodø on the Norwegian mainland) and other nationalities’ prospective air operations in the region were not included. Due to range limit ations, the Lynx and Super Puma helicopters in the region usually have to transport patients to Longyearbyen for treat- ment and/or transportatio n to the Norwegian mainland Figure 1 The Arctic Sea (http://benmuse.typepad.com/ben_muse/arctic/) . The white cover is the Arctic ice as in September 2007. The arrows points to Svalbard (northern end) and Tromsø (southern end). Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 2 of 8 is carried out by airplane. Most patients taken care of by the Lynx or Super Puma crews are thus indirectly included in our survey. The NAF’s Sea King helicopters operate on t he Norwegian mainland and along its coast- line. They very rarely operate in the Arctic. In February 2010, the LABAS database was a nalysed focussing on the time period between 1 January 1999 and 31 December 2009. The primary goal was to clarif y the variations in patients’ diagnosesandflightspattern around the year. The following data were registered: - Flight data: Date and ti me of start and end of task, time spent, state of emergency (non-urgent, urgent, emergent) according to the Norwegian Index for Medical Emergency Assistance [1], destination (hos- pital) and any delay of more than 15 min. - Patient data: Sex, age, nationality, diagnosis (according to the international classification of dis- eases, ICD), oxygen support, intubation, analgesics given, degree of seriousness [National Advisory Committee on Aeronautics (NACA) scale; the s cale is shown in Table 1], intravenous administrations and the use of vasopressor drugs. Statistical analysis The Microsoft Office Excel 2007, Microsoft Corp., Redmond, WA, was employed for the calculations and database. Statistical Package for Social Science (SPSS) version 16.0, SPSS Inc., Chicago, IL, was employed for statistical analyses. Cases with an unknow n value f or a particular variable were excluded from analysis involving that variable. Statistical analyses were performed employing descriptive stati stics and bivariate correlation analysis. All P-values are two tailed and considered sta- tistically significant when P < 0.05. No approval from the regional ethics committee was necessary as no individual patient identifiable data were accessed by the researchers. Results Three hundred forty-five patients and 321 flights were identified, and incidents were most c ommon in April, June, July and August. Details are shown in Figure 2. Patient and task characteristics are shown in Table 2. Most patients (93%) were transported to t he University Hospital of North Norway (UNN) (Figure 1). Heart and vascular disease together with bone fracture and infections w ere the most f requent diagnoses and constituted half of all cases (Table 2). One tenth of the patients had a gynaecologic/obstetric condition. Seaso- nal variations are shown in Figure 3. Half of all frac- tures occurred in April and August. The male/female ratio was 1.6 (inhabitants at Svalbard have a male/ female ratio of 1.3). Fractures were more common among the age group 40 – 60 years, but there was no statistically significant correlation between age and frac- tures (P = 0.833). Concerning severity, most (85%) cases scored 3 o r 4 on the NACA scale. Details are shown in Figure 4. There was a correlation between NACA score and age (P = 0.027). This was because heart and vascular disease was more common among the elderly. The mean NACA score among the heart and vascular disease group was 4.1 versus 3.3 among the controls. Three fourth of the cases were classified as urgent or emer- gent, and the state of emergency was correlated to heart and vascular disease (P = 0.020) and gynaecologic/obste- tric causes (P = 0.000). Most patients were transported during the daytime. Only 50 patients were handled during periods of polar night and 97 (28%) during the period of seasonable darkness. Few (14%) patients were handled between midnight and 08:00 a.m. Details are shown in Figure 5. No increase in the number of tasks was revealed during the study period (F igure 6). The mean time spent per flight (one way) was 3 h 33 min (range 1 h – 8h 35 min). Thirty-five transports were delayed, and the mean delay was 36 mi n. The specific cause of delay was not registered. Discussion Heart and vascular dis ease together with bone fractu res was the most frequent diagnosis. This has also been documented by other investigators [2,3]. Gynaecologic and obstetric causes accounted for 10% of patients. This is because pregnant w omen are routinely evacuated to the mainland for childbirth. A similar situation has been described among Canadian Inuit residents in the Canadian Arctic [4]. Researchers have commented that evacuation for childbirth has deleterious social and cul- tural effects [4]. Canadians have therefore recently established community birthing centres in Nunavik and Nunavut. This is not a current policy for the Norwegian Table 1 The National Advisory Committee on Aeronautics (NACA) scale Score level Patient status NACA 0 No injury or illness NACA 1 Not acute life-threatening disease or injury NACA 2 Acute intervention not necessary, further diagnostic studies needed NACA 3 Severe, but not life-threatening disease or injury; acute intervention necessary NACA 4 Development of vital (life-threatening) danger possible NACA 5 Acute vital (life-threatening) danger NACA 6 Acute cardiac or respiratory arrest NACA 7 Death Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 3 of 8 0 10 20 30 40 50 60 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Months Tasks perfrom ed Tas ks Figure 2 The number of patients transported each month of the year. Table 2 Overview of air ambulance operations in the Norwegian Arctic during the time period 1999 – 2009 Items Subgroup Patients % Median age (yrs) Range Patient characteristics All (n = 345) Age 345 100 47 0-92 Sex Female 117 34 41 2-88 Male 225 65 47 1-92 Sex not registered 3 1 Nationality Not Norwegian (total) 75 22 Russian 31 9 German 8 2 Swedish 5 1 British 2 0.4 Finnish 1 0.2 Faroe Island 1 0.2 Unspecified 27 8 Task characteristics Emergency status Non-urgent 84 24 Urgent 144 42 Emergent 117 34 Diagnosis Psychiatry 9 3 42 21-67 Infection 34 10 40 1-84 Heart and vascular disease 76 22 54 19-87 Bone fracture 71 21 48 2-80 Gynaecology/obstetrics 28* 8 29 20-40 Cancer/tumour 4 1 57 49-73 Treatment Intubation 4 1 Oxygen 204 59 Analgesics 135 39 Vasopressors 34 10 *Twenty-four of the patients were transported to give birth to their children on the mainland. Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 4 of 8 Arctic because of the limited number of women living in the region, risk factors and the capabilities (no per- manent access to a surgeon) at the local hospital unit. The high frequency of fractures in August has also been documented in a prior Norwegian study from the Norwegian Coast Guard [5]. The authors argue that this situation is caused by the fact that w orkers and fishermen are less cautious when returning to work after their summer holiday. Inthefuture,strokepatientsmaybecomeagrowing group among the air ambulance patients because there will be more elderly people and new treatment guide- lines. The role of a ir ambulance (helicopter) services in the transfer of stroke patients has been illustrated by 0 10 20 30 40 50 60 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Patients Months Fractures Vascular disease Infections All patients Figure 3 The number of patients transported per month according to the main diagnostic groups (infection, vascular disease and fracture). 0 20 40 60 80 100 120 140 160 180 200 01234567 NACA score Number of patients Figure 4 The NACA score distribution among the patients. Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 5 of 8 Thomas and colleagues [6]. Prior to thrombolytic ther- apy, a CT scan has to confirm the diagnosis. Becaus e of the limited time window between symptom onset and initiation of therapy, an air ambulance service is impor- tant for the hasty transfer of patients to the mainland for CT scanning. We have documented the logistics of the air ambu- lance service in the Norwegian Arctic and the varia- tions around the year. Whereas the geography of northern Norway makes it necessary to include both airplanes and helicopters in the service, many countries employ helicopter emergency medical services (HEMS) alone [7,8]. However, HEMS has limitations. In north- ern Norway rough weather conditions are a significant problem, especially during winter. A study from the region revealed an ac cess rate of o nly 40% between November and March [9]. Even in northern Norway, ground transportation may be a good alternative [10,11]. However, because of the lack of roads and long distances, ground transportation is of limited value in the Arctic When appropriate, sea transport maybeanalternative. 0 5 10 15 20 25 30 35 0 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Patients (numbers) Time 0-24 hours Figure 5 The number of patients transported according to time (0 – 24 h) of takeoff (0 = midnight). 0 5 10 15 20 25 30 35 40 45 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Tasks Year Figure 6 The number of patients transported each year. Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 6 of 8 Despite the patients being airborne, there was a signif- icant one-way flying time. Such a time span has also been shown employing heavy search and rescue helicop- ters in the Barents Sea [12]. The complexity of running operations in remote and cold regions has been illu- strated in Antarctica [13]. In this report a ski-equipped airplane was employed, a nd a critically ill patient was transported 9 h north to New Zealand. Daylight returns to Svalbard in early March, and in April people perform many outdoor activities. Dog sleds and especially snowmobiles are common means of transport. The sunlight reflected by the white cover of snow may cause “white out” and consequently an incre ased risk of accidents. Svalbard has the highest fre- quency of snowmobile accidents worldwide [14-16]. During a 3-year period (1997 – 2000), 107 snowmobile injuries were registered [15]. Most i njuries (79.4%) occurred in the time period between March and May. This is in accordance with the peak of fractures in April shown in our survey. In the future, significant changes will occur in the Arctic. As the ice is melting because of worldwide cli- mate changes, shipping may take advantage of new routes among Europe, Northern Russia, Asia and North America. Furthermore, polar adventure operations will become steadily more popular as the coast areas of northern Greenland and north of Svalbard will be avail- able for longer periods. In such a setting, Svalbard may become an important base for air ambulance services in the Arctic. Air ambulance service is costly and limited in terms of resources, especially in the Arctic [17]. It should there- fore be discussed whether passengers participating in polar adventure operations must have a declaration from their personal p hysician that they are fit for the journey. Such operations are very different from “tropi- cal” cruise lines [18]. To achieve maximum value (health gain) for the money, an excellent fleet coordination system is manda- tory. Furthermore, high-quality decision criteria for aeromedical evacuation are important [19-21]. This has been summarised with the words “right patient, place and time” [20]. Another limitation has b een the access to competent crew members [22]. As long as the Norweg ian government decides to keep and support the Norwegian municipalities on Svalbard, a basic health care infrastructure has to be funded. In light of the potential (shipping, fishery, oil/gas industry) develop- mentoftheArcticregion,aparallelexpansionofthe health care infrastructure should be considered. Conclusion The NNRHA trust has been responsible for safe air ambulance operations in the Arctic, serving both Norwegians and others. The pressure on the limited resources is strongest in April, June, July and August. In the future, shipping and polar adventure operations will increase the need for health care ser- vices in the Arctic, especially during summer and autumn. This should be focussed on in future model-based analysis. Acknowledgements The authors wish to thank the personnel at the library of the University of Tromsø for their support. Useful comments from colleagues at the NNRHA are also appreciated. Funding The study was funded by the Northern Norway Regional Health Authority. Author details 1 Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway. 2 Department of Oncology, University Hospital of North Norway, N-9038 Tromsø, Norway. 3 Northern Norway Regional Health Authority, N-8038 Bodø, Norway. Authors’ contributions Both TME and JN took part in the design of the study. TME collected the data from the LABAS database and made overviews of the material. JN carried out the statistical analysis, searched the PubMed database for relevant studies/reports and wrote the article. All authors read and approved the final manuscript. Author Information The author is a medical oncologist, professor at the Faculty of Medicine at the University of Tromsø and medical director at the North Norway Regional Health Authority. Competing interests The authors declare that they have no competing interests. Received: 10 April 2010 Accepted: 27 January 2011 Published: 27 January 2011 References 1. Norwegian Medical Association: Norwegian Index for Medical Emergency Assistance. The Laerdal Foundation for Acute Medicine, Stavanger, Norway, 2.1 2005. 2. Zakariassen E, Burman RA, Hunskaar S: The epidemiology of medical emergency contacts outside hospitals in Norway. A prospective population based study. Scand J Trauma Res Emerg Med 2010, 18:9 [www. sjtrem.content/18/1/9]. 3. Ulvik A, Rannestad BS, Carlsen AW, Nielsen EW: Rescue helicopter service in Bodø. Advanced emergency service or alternative transportation? J Norw Med Assoc 2002, 122(1):25-29. 4. Douglas VK: Childbirth among the Canadian Inuit. A review of the clinical and cultural literature. Int J Circumpolar Health 2006, 65(2):117-132. 5. Norum J, Endresen E: Injuries and diseases among commercial fishermen in the Northeast Atlantic and Barents Sea. Data from the Royal Norwegian Coast Guard. Int Arch Occup Environ Health 2003, 76(3):241-245. 6. Thomas SH, Kociszewski C, Schwamm LH, Wedel SK: The evolving role of helicopter emergency medical services in the transfer of stroke patients to specialized centres. Prehosp Emerg Care 2002, 6(2):210-214. 7. Ringburg AN, Thomas SH, Steyerberg EW, Van Lieshout EM, Patka P, Schipper IB: Lives saved by helicopter emergency medical services. An overview of literature. Air Med J 2009, 28(6):298-302. 8. McVey J, Petrie DA, Tallon JM: Air versus ground transport of the major trauma patient: A natural experiment. Prehosp Emerg Care 2010, 14:45-50. 9. Haug B, Avall A, Monsen SA: Reliability of air ambulances. A survey in three municipalities in Helgeland. J Nor Med Assoc 2009, 129(11):1089-1093. 10. Nielsen EW: Keep your feet on the ground. J Nor Med Assoc 2009, 129(11):1088. Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 7 of 8 11. Norum J, Elsabk TM: The ambulance services in northern Norway 2004 – 2008. Improved competence, more tasks, better logistics and increased costs. Int J Emerg Med 2010. 12. Haagensen R, Sjøborg KA, Rossing A, Ingilae H, Markengbakken L, Steen PA: Long range rescue helicopter missions in the Arctic. Prehosp Disaster Med 2004, 19(2):158-163. 13. Ogle JW, Dunckel GN: Defibrillation and thrombolysis following a myocardial infarct in Antarctica. Avial Space Environ Med 2002, 73(7):694-698. 14. Ytterstad B, Dahlberg T: Snowmobile injuries in Svalbard. J Norw Med Assoc 2005, 125(23):3252-3255. 15. Ytterstad B, Norheim J: Snowmobile injuries in Svalbard – a three years study. Int J Circumpolar Health 2001, 60(4):685-695. 16. Ytterstad B, Norheim AJ: The epidemiology of injuries in Svalbard compared with Harstad. Int J Circumpolar Health 2001, 60(2):184-195. 17. Ringburg AN, Polinder S, Meulman TJ, Steyerberg EW, Van LIeshout EMM, Patka P, Van Beeck EF, Schipper IB: Cost-effectiveness and quality of life analysis of physician-staffed helicopter emergency medical services. Br J Surg 2009, 96:1365-1370. 18. Curry CH: Death in Antarctica. Med J Austr 2002, 176(9):451. 19. Duchateau FX, Verner L, Cha O, Corder B: Decision criteria of immediate aeromedical evacuation. J Travel Med 2009. 20. Isakom A: Urgent air-medical transport: Right patient, place and time. Can Med Assoc J 2009, 181(9). 21. Tomazin I, Kovacs T: Medical considerations in the use of helicopters in mountain rescue. High Alt Med Biol 2003, 4(4):479-483. 22. Littlewood N, Parker A, Hearns S, Corfield A: The UK helicopter ambulance tasking study. Injury Int J Care Injured 2010, 41:27-29. doi:10.1186/1865-1380-4-1 Cite this article as: Norum and Elsbak: Air ambulance services in the Arctic 1999-2009: a Norwegian study. International Journal of Emergency Medicine 2011 4:1. Submit your manuscript to a journal and benefi t from: 7 Convenient online submission 7 Rigorous peer review 7 Immediate publication on acceptance 7 Open access: articles freely available online 7 High visibility within the fi eld 7 Retaining the copyright to your article Submit your next manuscript at 7 springeropen.com Norum and Elsbak International Journal of Emergency Medicine 2011, 4:1 http://www.intjem.com/content/4/1/1 Page 8 of 8 . ORIGINAL RESEARCH Open Access Air ambulance services in the Arctic 1999-2009: a Norwegian study Jan Norum 1,2,3* , Trond M Elsbak 3 Abstract Background: Air ambulance services in the Arctic have. helicopter at Longyearbyen), the Norwegian Air Force (NAF; operating Sea King helicop- ters at Banak and Bodø on the Norwegian mainland) and other nationalities’ prospective air operations in the region. logistics of the air ambu- lance service in the Norwegian Arctic and the varia- tions around the year. Whereas the geography of northern Norway makes it necessary to include both airplanes and helicopters